Bryan R. Parry

Identification of the fascia propria by magnetic resonance imaging and its relevance to preoperative assessment of rectal cancer

PURPOSE: If rectal cancer does not penetrate the fascia propria of the rectum and the rectum is removed with the fascial envelope intact (extrafascial excision), then local recurrence of the cancer will be minimal. Modern imaging techniques have identified a fascial plane surrounding the rectum and mesorectum, and it has been suggested that this is the fascia propria. The aim of this study was to identify whether this plane is the rectal fascia propria and whether tumor invasion through this fascia can be identified preoperatively. METHODS: Two separate experiments were performed: 1) pelvic magnetic resonance imaging was performed before and after dissection and marking of the plane of extrafascial dissection of the rectum of a cadaver; and 2) magnetic resonance imaging was performed in 43 rectal cancer patients preoperatively. Two radiologists independently reported the depth of tumor invasion in relation to the fascia propria. The tumors were resected by extrafascial excision, and a pathologist independently reported the relation of the tumor to the fascia propria. RESULTS: The marker inserted in the extrafascial plane showed that the plane visualized on pelvic magnetic resonance imaging was the fascia propria dissected in extrafascial excision of the rectum. The magnetic resonance imaging detected tumor penetration through the fascia propria with a sensitivity of 67 percent, a specificity of 100 percent, and an accuracy of 95 percent. CONCLUSION: The surgical fascia propria can be identified on preoperative magnetic resonance imaging in patients with rectal cancer. Tumor invasion through this fascia can be detected on magnetic resonance imaging. This method of assessment offers a new way to select those patients who require preoperative radiotherapy.

Increased expression of the mRNA for hormone-sensitive lipase in adipose tissue of cancer patients

The expression of genes coding for regulatory enzymes involved in the uptake, synthesis and mobilisation of lipid was measured in adipose tissue of cancer patients. Total RNA was isolated from subcutaneous adipose tissue of control and cancer patients and the various mRNAs measured by Northern blot analysis. The total lipoprotein lipase enzymic activity and the relative levels of the mRNAs for lipoprotein lipase and for fatty acid synthase were not significantly different between cancer patients and control patients. However, there was a significant two-fold increase in the relative level of mRNA for hormone-sensitive lipase (HSL) in adipose tissue of cancer patients compared with control patients. The cancer patients also exhibited a two-fold elevation in serum triacylglycerol levels and serum free fatty acid levels. There was a significant correlation between the serum free fatty acid level and expression of HSL mRNA in the adipose tissue. The serum levels of insulin and tumour necrosis factor-alpha were not different between cancer and control patients. The results suggest that at least one of the mechanisms for depletion of lipid from adipose tissue in cancer patients operates at the level of increased expression of mRNA of the lipolytic regulatory enzyme, hormone-sensitive lipase.

Clinical variables associated with positive angiographic localization of lower gastrointestinal bleeding.

Background:  Localizing the source of severe lower gastrointestinal (GI) bleeding is often difficult but is important to plan the extent of colonic resection. The purpose of the present paper was to audit the Auckland Hospital experience of selective angiography, in localizing lower GI bleeding.

Rectal duplication cyst presenting as perianal sepsis: report of two cases and review of the literature.

INTRODUCTIONRecurrent perianal sepsis is a difficult problem to manage in colorectal surgical practice. One cause is rectal duplication cyst, a rare congenital lesion that is easily overlooked. Many cases have associated congenital defects, especially musculoskeletal anomalies, and may provide a clue to the underlying condition. Early diagnosis is important because these cysts do not resolve spontaneously and may undergo malignant change.METHODSWe present two cases of middle-aged females who presented with perianal sepsis secondary to rectal duplication cyst. The first case had numerous surgical procedures for a perianal fistula during a ten-year period. She had associated sacral anomalies consistent with Currarino syndrome. The second case presented with a perineal mass after a bout of perianal inflammation. Both cases had the entire cyst surgically excised.RESULTSThere were no complications postoperatively and no recurrence at follow-up. Histopathology revealed no malignancy in the cyst.CONCLUSIONSRectal duplication cyst is a rare cause of recurrent perianal sepsis that should be considered in difficult cases, especially in those with associated musculoskeletal anomalies. Complete surgical excision is the preferred treatment to prevent recurrence and the risk of malignant degeneration.

Judgment Analysis of Surgeons’ Prioritization of Patients for Elective General Surgery:

Background . Access to elective general surgery in New Zealand is governed by clinicians’ judgment of priority using a visual analog scale (VAS). This has been criticized as lacking reliability and transparency. Our objective was to describe this judgment in terms of previously elicited cues. Methods . We asked 60 general surgeons in New Zealand to assess patient vignettes using 8 VAS scales to determine priority. They then conducted judgment analysis to determine agreement between surgeons. Cluster analysis was performed to identify groups of surgeons who used different cues. Multiple regression for the combined surgeons was undertaken to determine the predictability of the 8-scale VAS. Results . Agreement between surgeons was poor (ra = 0.48). The cause of poor agreement was mostly due to poor consensus (G) between surgeons in how they weighted criteria. Using cluster analysis, we classified the surgeons into 2 groups: 1 took more account of quality of life and diagnosis, whereas the other group placed more weight on the influence of treatment. The 8-scale VAS showed good predictability in assigning a priority score (R 2 = 0.66). Discussion . The level of agreement reflects surgeons’ practice variation. This is exemplified by 2 distinct surgeon groups that differ in how criteria were weighted.

Prioritizing patients for elective surgery: Clinical judgement summarized by a Linear Analogue Scale

Background:  The New Zealand health reforms have resulted in the requirement that surgeons utilize Clinical Priority Access Criteria (CPAC) to ration patient access to elective surgery. The validity of the tools used as CPAC has been challenged. An alternative tool, the Linear Analogue Scale (LAS), is therefore used in our institution. Our objectives were to determine the variables that influence the priority score generated using the LAS, and the length of time waited by patients awaiting general surgical procedures.

EXPERIENCE WITH THE USE OF VACUUM DRESSINGS IN THE MANAGEMENT OF ACUTE ENTEROCUTANEOUS FISTULAS

High‐output enterocutaneous fistulas involving an open abdominal wound are a difficult management problem. We report our experience on the use of vacuum dressings. The potential benefits, problems and new recommendations for the use of vacuum dressings in the management of enterocutaneous fistulas are discussed.